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Thyroid cancer is the most common endocrine malignancy, and its incidence is increasing. Differentiated thyroid cancer is the most common type and papillary thyroid carcinoma is the most common type of differentiated thyroid cancer. This work aimed to study long noncoding (Lnc) RNA homeobox transcript antisense RNA (HOTAIR) expression in plasma and serum midkine, a heparin binding growth factor, as biomarkers of thyroid cancer. This study included 27 thyroid cancer patients, 29 patients with benign thyroid disease and 26 individuals as normal controls. HOTAIR expression was assessed by real time polymerase chain reaction and midkine by ELISA. These biomarkers were elevated in thyroid cancer patients than patients with benign thyroid diseases and controls. Patients with thyroid cancer stage III had higher midkine levels in comparison to those with stage-I and stage-II (p0.001). Patients with grade II had higher midkine in comparison to those with grade I (p0.001). Statistically significant elevation of HOTAIR expression was found in stage III and stage II (p=0.001), compared to stage I. However, no difference was observed between stage II and stage III (p=0.533). There was no difference in both biomarkers in different histopathological types of thyroid cancer. ROC analysis was used for detection of thyroid cancer, midkine had AUC of 0.95 at a cutoff 897.5 pg/ml with a sensitivity of 98.0%, and specificity of 81.5% (p0.001). HOTAIR had AUC of 1 at a cutoff 11.8-fold change with a sensitivity and specificity of 100 %, (p0.001). We concluded that HOTAIR has high sensitivity and specificity in detection of thyroid cancer. It was correlated with tumor stage but not with histopathological types.

Background The coronavirus pandemic has caused global disruption to all aspects of life. This disturbance has been most notable in the medical world. Political, societal, medical, and behavioral alterations have forced emergency surgical practices to adapt. This study investigated the impact of coronavirus 2019 (COVID-19) at a busy surgical center. Methodology This is a retrospective observational study. Three study periods were analyzed: pre-COVID, first wave, and second wave. Data were collected on referrals, diagnoses, investigations, management pathways, outcomes, patient behavior, and consultant practice. A one-way analysis of variance (ANOVA test) was used for the analysis of parametric data and the Mann-Whitney U test for non-parametric data. Results Declining numbers of patients presented across the three periods. There was a severe disruption in performing emergency general surgeries during the first wave, propagated by alterations in clinical decision-making, as well as fluctuations in societal and patient behavior. Despite the effects of the second wave being significantly more profound in terms of hospitalization and COVID-related mortality, a paradoxical, gradual return to the norm was noted, which was seen in referral pathways, imaging decisions, and management strategies. Conclusion Our data is suggestive of society, both within and outside the medical sphere, adjusting to life with COVID-19.

Objective: The purpose of this study was to evaluate short-term oncological and perioperative outcomes of using Pfannenstiel incision for the surgical staging of endometrial carcinoma. Methods: This was a retrospective cohort study. All patients with endometrial carcinoma referred to the Department of Surgical Oncology, South Egypt Cancer Institute, for surgical staging between January 1, 2014, and July 1, 2016, were enrolled. The patients were grouped according to the type of surgical incision either through Pfannenstiel incision or midline incision, and the groups were compared. Demographic, clinical, operative, and short-term oncological features were analyzed. Results: A total number of 117 patients were recruited, of which 45 patients had Pfannenstiel incision, and 72 patients had midline incision. The clinical and pathological features of patients in both groups were similar. The operative outcomes showed no significant difference between the groups (p > 0.1). Postoperatively, the Pfannenstiel incision group had a statistically significant lower rate of complications compared to the midline incision group (15.5% vs. 38.9%, p = 0.02). The short-term oncological outcomes in the form of total procured lymph nodes or para-aortic lymph nodes were not statistically different (p > 0.1). Conclusion: Pfannenstiel incision can be safely performed for the surgical staging of endometrial cancer with acceptable oncological outcomes compared to the midline incision.

Background: Our study aimed to evaluate the clinical utility of detecting plasma microRNAs (miR-21 & miR-92a) for diagnosis of colorectal cancer patients and its relation to tumor staging. Patients and Methods: Quantitative real-time RT-PCR was applied to determine the relative expression level of miR-21 and miR-92a in serum. The sensitivity and specificity of these markers were evaluated by receiver operating characteristic (ROC) curve analysis. Final staging of colorectal cancer cases was assigned according to results of histopathologic examination of surgically resected specimens. Results: This study included 52 cases of colorectal cancer (CRC), 20 cases of precancerous colorectal lesions, and 20 healthy controls. Both Plasma miR-21 and Plasma miR-92a were significantly higher in CRC group compared to both the control group and precancerous group. Also, they were significantly higher in advanced CRC stages than early CRC stages. The sensitivity and specificity of miR-21 for discriminating CRC from controls were found to be 90.38% and 100.0%, respectively. However, for miR-92a, sensitivity and specificity were found to be 94.23% and 100.0%, respectively. For discriminating CRC cases from precancerous lesions, the sensitivity and specificity of miR-21 were found to be 75.08% and 95.0%, respectively. However, for miR-92a, sensitivity and specificity were found to be 80.77% and 100.0%, respectively. Conclusions: both plasma miR-21 and miR-92a have significant value for early detection of CRC as non-invasive screening molecular biomarkers with high sensitivity and specificity. They also help for differentiation between patients with benign and malignant colorectal lesions and those with early and advanced CRC.

To assess the utility of MDCT tumor–vascular interface criteria for predicting vascular invasion and resectability in borderline pancreatic cancer (BRPC) patients after neoadjuvant therapy (NAT). This prospective study included 90 patients with BRPC who finished NAT, showed no progression in preoperative CTs and underwent surgery. Two radiologists independently assessed preoperative vessel-tumor interface criteria. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for predicting vascular invasions and resectability using surgical and pathological results as the gold standard. Inter-reader agreement was assessed using the κ coefficient. Pathologic vascular invasion was confirmed in 47 (54.7%) veins and 14 (16.3%) arteries. R0 resection was achieved in (82.6%71/86) pancreatic resection. Using criteria of circumferential interface ≥ 180 degrees with contour deformity ≥ grade 3 and/or length of tumor contact > 2 cm to predict vascular invasion, the AUCs for the two readers were 0.85–0.88 for arterial invasion and 0.92–0.87 for venous invasion. Using criteria of circumferential interface ≤ 180° with contour deformity ≤ grade 2 and/or length of tumor contact

Rationale and Objectives The purpose of this study was to compare the accuracy of MDCT and laparoscopy in the prediction of peritoneal carcinomatosis index score. Reproducibility of MDCT interpretation was also assessed. Methods This prospective study included 85 ovarian cancer patients underwent MDCT and diagnostic laparoscopy before cytoreductive surgery. We calculated the accuracy of diagnostic modalities in the calculation of the peritoneal cancer index score (PCI). Radiologist interobserver agreement was calculated using kappa statistics. Results Nine hundred-thirty (84.2%) of the 1105 regions had peritoneal deposits at exploratory laparotomy. Computed tomography (CT) and laparoscopy sensitivity were 94.9%, 98.3%, specificity 86.7%, 80.4%, PPV 97.9 %, 96.8%, NPV 72.2%, 88.8 %, and accuracy 93.8 %, 95.7%, respectively. However, computed tomography (CT) diagnostic performance is less accurate than laparoscopy in pelvic and small intestinal regions; no statistically significant differences were evident regarding total PCI score compared to surgery (p> 0.05). CT and laparoscopy correctly depicted peritoneal carcinomatosis in 88.2%, 90.6% of patients, respectively. Optimal cytoreduction was achieved in 68 (80%) patients. Conclusion Both CT and laparoscopy seems to be effective tools for assessment of peritoneal carcinomatosis using the PCI score. Dedicated MDCT protocol with routine use of a standardized PCI form may provide better comprehensive multi-regional analysis that may help surgeons referring patients to the best treatment option. Laparoscopy is a valuable tool in cases with a high risk of suboptimal cytoreduction related to disease extent.

Breast cancer is one of the most malignant tumors in women across the globe. Diagnosis of breast cancer at early stages is essential to improve treatment outcomes and decrease mortality rates. There is a pressing need for new non-invasive biomarkers to improve early diagnosis of breast cancer. This study aims to assess plasma miR-27a for the early diagnosis of breast cancer. miR-27a was evaluated in a total of 95 blood samples, 40 newly diagnosed cancer patients, 20 patients with benign breast lesions, 20 females with positive family history for breast cancer and 15 apparently healthy controls, using quantitative real time polymerase chain reaction. Our results exhibited significantly higher expression level of plasma miR-27a in breast cancer patients (median= 8.3 and 19 fold change for early and late stages respectively) compared to controls, high risk group and benign group with (P0.001) for each. Plasma miR-27a was significantly higher in late breast cancer (median=19 fold change) compared to early breast cancer (median= 8.3) with (P0.001). There was no statistically significant difference of plasmamiR-27a levels in benign group (median=1.8 fold change) compared to both control group and high risk group. There was no statistically significant difference of plasma miR-27a levels in high risk group (median= 1.2 fold change) compared to control group (median= 1 fold change). We performed Receiver Operating Characteristic (ROC) analysis for discriminating malignant from non-malignant cases. Plasma miR-27a yielded an area under the curve (AUC) of 0.983 with sensitivity 97.5%, specificity 91% and accuracy 94%.We concluded that miR-27a expression level represents sensitive and specific non-invasive molecular biomarkers for diagnosis of breast cancer.

To assess the utility of MDCT tumor-vascular interface criteria for predicting vascular invasion and resectability in borderline pancreatic cancer (BRPC) patients after neoadjuvant therapy (NAT).This prospective study included 90 patients with BRPC who finished NAT, showed no progression in preoperative CTs and underwent surgery. Two radiologists independently assessed preoperative vessel-tumor interface criteria. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for predicting vascular invasions and resectability using surgical and pathological results as the gold standard. Inter-reader agreement was assessed using the κ coefficient.Pathologic vascular invasion was confirmed in 47 (54.7%) veins and 14 (16.3%) arteries. R0 resection was achieved in (82.6%71/86) pancreatic resection. Using criteria of circumferential interface ≥ 180 degrees with contour deformity ≥ grade 3 and/or length of tumor contact 2 cm to predict vascular invasion, the AUCs for the two readers were 0.85-0.88 for arterial invasion and 0.92-0.87 for venous invasion. Using criteria of circumferential interface ≤ 180° with contour deformity ≤ grade 2 and/or length of tumor contact 2 cm to predict R0 resection, the AUCs was 0.85-0.86 for the two readers. The overall inter-reader agreement was good (κ = 0.75-0.80). The κ values for venous invasion, arterial invasion and R0 resection were 0.76, 0.78, and 0.80.Tumor-vessel criteria demonstrated good diagnostic performance and reproducibility in the prediction of vascular invasion after NAT in BRPC. These criteria could be helpful in the prediction of R0 resection in cases with only venous involvement.

The feasibility of a laparoscopic approach in patients who have had a prior laparotomy (PL) remains controversial. We hypothesized that laparoscopic colorectal resection was safe and feasible in patients with previous open abdominal surgery. A retrospective review (2007–2015) of all patients undergoing laparoscopic resection for sigmoid and rectal adenocarcinoma with or without prior midline laparotomy (NPL) was performed. Primary endpoints included conversion and perioperative morbidity. Secondary endpoints included length of stay and perioperative outcomes. Demographics, surgical history, oncologic staging, and short-term outcomes were reviewed. We identified 211 patients, of whom 33 (15.6%) had a prior laparotomy. Significantly more patients in the PL group were female (76.2 vs. 52.8%, p = 0.004). Patients with PL were of similar age to NPL patients (69.3 vs. 62.5, p = 0.09), and comorbidities, tumor staging, and neoadjuvant therapy were comparable between groups (all p > 0.05). Additional trocar placement was significantly higher in PL group (33.3 vs. 17.4%, p = 0.03), while conversion rate did not reach statistical significance (24.2 vs. 12.9%, p = 0.08). The postoperative complication rate was comparable between PL and NPL patients (33.3 vs. 25.3%, respectively, p = 0.2). Prior laparotomy should not be a contraindication to patients undergoing laparoscopic colorectal surgery, though surgeons should anticipate a higher likelihood of conversion to open.

Background Surgeons often approach anal fissure with chemical denervation (Botulinum toxin, BT) instead of initial lateral internal sphincterotomy (LIS) due to concerns for long-term incontinence. We evaluated the characteristics and outcomes of patients who received BT or LIS. Methods We performed a retrospective chart review of patients undergoing LIS and BT for anal fissure between 2009 and 2015. In 2015, a telephone survey was performed to evaluate durability, long-term incontinence and patient satisfaction. Results Ninety-four patients met criteria: 73 LIS and 21 BT. Age (BT 49 vs. LIS 52) was similar between groups (p = 1.0). Cleveland Clinic Fecal Incontinence (CCFI) score pre-intervention was higher in BT than LIS patients (2.1 vs. 0.4, p = 0.007) with fewer BT patients with perfect continence (50% vs. 88%). Telephone survey response was 61%. Fissure recurrence was significantly higher for BT than LIS patients (36% vs. 9%, p = 0.03). Conclusion Patients undergoing LIS were less likely to recur. Both LIS and BT patients had some durable changes in continence raising the question of whether there is a safe technique.

Introduction Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. Methods A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. Results There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. Conclusions APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes.

Background: Laparoscopic radical gastrectomy for cancer has significant short- and long-term advantages. The feasibility and safety of laparoscopicdistal gastrectomy for cancer (LADG) is unclear in low to middle income countries as resources are limited. Therefore, the aim of this study was to evaluate the safety and feasibility of (LADG) in low to middle income countries; Egypt as an example. Methods: Thirty four Patients with stage I-II cancer at the pylorus and antrum have been enrolled for LADG between 2012 and 2015 with the reuse of single use vascular sealing device has been evaluated. Results: Finally 27 patients had been included in the study and successful LADG has been done for all selected cases. The average operative time was 151 ± 10 minutes. The average estimated blood loss was 73.3 ± 13 ml. No intra-operative complications have been recorded. The average time for post-operative patient ambulation was 9 hours (SD ± 1.8) and for oral fluid intake was 3.5 SD ± 1 days. The average duration of the hospital stay was 9.3 ± 1.2 days. The average number of retrieved lymph nodes was 21.7 ± 3.8 days. All the cases had free surgical margin. The median number of reuse of the vascular sealing device was 3.8 times (3 - 5 times). Conclusion: Laparoscopic distal gastrectomy for cancer could be safe and feasible in developing countries and give similar results for that of developed countries. Safe reuse of single use expensive parts of some instruments for laparoscopy could help in utilization of these advanced surgeries in low to middle income countries. Long term follow up as well as comparative studies with open surgery are required.

Introduction Dextran sodium sulfate (DSS) is commonly used to induce a murine fulminant colitis model. Hepatocyte growth factor (HGF) has been shown to decrease the symptoms of inflammatory bowel disease (IBD) but the effect of its activator, HGFA, is not well characterized. Arginine reduces effects of oxidative stress but its effect on IBD is not well known. The primary aim is to determine whether HGF and HGFA, or arginine will decrease IBD symptoms such as pain and diarrhea in a DSS-induced fulminant colitis murine model. Methods A severe colitis was induced in young, male Fischer 344 rats with 4% (w/v) DSS oral solution for seven days; rats were sacrificed on day 10. Rats were divided into five groups of 8 animals: control, HGF (700 mcg/kg/dose), HGF and HGFA (10 mcg/dose), HGF and arginine, and high dose HGF (2800 mcg/kg/dose). Main clinical outcomes were pain, diarrhea and weight loss. Blinded pathologists scored the terminal ileum and distal colon. Results DSS reliably induced severe active colitis in 90% of animals (n = 36/40). There were no differences in injury scores between control and treatment animals. HGF led to 1.38 fewer days in pain (p = 0.036), while arginine led to 1.88 fewer days of diarrhea (P = 0.017) compared to controls. 88% of HGFA-treated rats started regaining weight (P, Highlights • We developed a fulminant colitis model in adolescent rats. • The fulminant colitis model reproduces inflammatory bowel disease in humans. • The rats were treated with hepatocyte growth factor, its activator, and arginine. • The HGF treated rats had fewer days of pain. • The arginine treated rats had fewer days of diarrhea.

BACKGROUND Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery. OBJECTIVE The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure. DESIGN This was a retrospective review. SETTINGS The study was conducted at a tertiary referral center. PATIENTS Patients who underwent ileostomy closure (2006-2015) were stratified into early (≤48 hours) and late discharge groups. MAIN OUTCOME MEASURES The Modified Frailty Index, morbidity, and readmission rates were measured. RESULTS A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of

Background Intraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. Methods A retrospective review (1999–2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. Results There were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. Conclusion IORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.

Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. A retrospective review (2010–2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4–7) versus control 6 (4.75–9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance. The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

Background: Gallbladder cancer (GBC) represents the most common and aggressive biliary tract cancer with overall 5-year survival being only 5%– 10%. Survival following resection, especially in early stages, has shown some improvement due to advances in surgical treatment. Advanced stages, however, continue to have dismal outcome. Complete surgical resection offers the only chance for cure, which extended from simple cholecystectomy to major hepatectomy or enbloc resection of adjacent organs. The aim of this study was to examine the predictors of longterm survival in patients with gall bladder cancer. Methods: We retrospectively evaluated 38 patients who underwent curative (R0) resection for GBC between January 2001 and December 2010 in Surgical Oncology Department, South Egypt Cancer Institute, Assiut University, Egypt. Surgical procedures included simple cholecystectomy (10.5%), radical cholecystectomy (75.4%), bile duct resection (33.8), and right hepatectomy (7.8%). Adjacent organ resection was performed in (23.4%), duodenal sleeve resection (10.4%), segmental colectomy (5.2%), segmental gastrectomy (2.6%), Hepatopancreaticoduodenectomy (5.3 %). Adjuvant chemotherapy was given for (68.4%) of patients and adjuvant radiotherapy for (36.8%) of patients. Median follow up period of the patients was 38 months (0.5-69 months). Results: The median disease free survival (DFS) for GBC patients was 38 months. Univariate analysis revealed that patient’s age, comorbidities, weight loss, jaundice, tumor differentiation, organ invasion, lymph node metastasis, perineural invasion, tumor stage and chemotherapy were associated with the patient’s survival. Of these, weight loss, jaundice, lymph node metastasis and tumor stage were found to influence the overall survival on the multivariate Cox Hazard Regression analysis. First year overall survival estimate was 86.84% ±5.5%, 2nd year = 71.05% ± 7.4%, Third year 60.53% ± 7.9% fifth year =15.79% ± 5.9%. Conclusion: Curative surgical resection remains the only effective approach for treatment of GBC. This study confirms that jaundice, weight loss and aggressive tumor (advanced stage and regional lymph nodes metastasis) are predictors of poor prognosis.

e15076Background: The prognostic significance of mucinous colorectal carcinoma (MC) is controversial, potentially due to heterogonous nature of populations studied. Clinically, we noticed that the ...

In this study, we aim to report the efficacy of using the anterior approach (AA) versus the conventional approach (CA), in surgical resection for large hepatocellular carcinoma (HCC) (≥7 cm) of the right hepatic lobe in terms of surgical and long-term outcomes. Between 2000 and 2006, 138 consecutive patients who underwent hepatic resection with curative intent for large right lobe HCC ≥7 cm were identified from a retrospective database. The 40 patients who had AA were compared with the remaining 98 patients who had CA. Clinicopathological features and surgical results were analyzed and prognostic factors were evaluated by multivariate analysis. There was no significant difference between the two groups as regards clinical, laboratory, and pathological parameters. The operative results had shown a comparable proportion of patients who experienced massive operative blood loss and postoperative complications in the two groups. The AA group had a lower recurrence rate (P = 0·015), better disease-free survival (DFS) (P = 0·001), and overall survival than the CA group. Our study identified that AA is a prognostic factor of both overall survival and disease-free survival for large HCC ≥7 cm. The AA is a safe and effective technique for right hepatic resection for large HCC and achieves more advantageous long survival outcome over the CA.